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Thousands of deaths in Victoria have not been referred to the proper authorities, potentially putting public health and safety at risk, a coroner says.

Between 2003 and 2011, more than 4200 deaths were reported from Births, Deaths and Marriages to the Coroners Court, rather than by medical professionals. Just over one-quarter should have been reported to the court for further examination, an investigation has found.

Between July 2010 and June 2011, 320 deaths were discovered that should have been immediately reported to the court.

Medical practitioners are legally required to notify the Coroners Court "without delay" of a "reportable" death - where it appears a death has been unexpected, unnatural, or violent, or has occurred from injury or accident, either directly or indirectly. It is a criminal offence not to do so.

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The coroner then decides if an inquest should be held, and to investigate further and determine the cause of death. They also have a role to promote public health and safety - but experts believe this role is misunderstood in the medical profession.

In a recent finding, coroner Heather Spooner said this recurring failure to report deaths was preventing coroners from completely investigating deaths.

"Failure to report also provides a missed opportunity to identify if there was any ability to contribute to the reduction of the number of preventable deaths and the promotion of public health and safety," she said.

"This is one of the fundamental purposes of the Coroners Act and the role of a coroner's investigation."

Ms Spooner made the comments in her finding into the death of 30-year-old Fikri Memedovski, who died at Dandenong Hospital of a heroin overdose in November 2009. The death was not referred to the coroner; the hospital's intensive care unit registrar wrote a death certificate stating the cause of death as a brain herniation, hypoxic brain injury and respiratory arrest.

Births, Deaths and Marriages referred the case to the coroner.

During the inquest earlier this year, Ms Spooner heard from expert witnesses David Ranson, the deputy director of the Victorian Institute of Forensic Medicine, and Sandra Neate, an emergency medicine specialist. Both review Births, Deaths and Marriages cases.

"Medical practitioners appear to have knowledge deficits with respect to how to complete a death certificate accurately and what constitutes a reportable death, as described in the Coroners Act," Dr Neate testified.

Associate Professor Ranson said some doctors feel they are protecting families, reluctant about an autopsy or further involvement after the death, by not reporting it to the coroner.

"The coroner has a very important role in assisting public health but that role, I think, is poorly understood out there in the medical community generally," he said.

Of the cases referred to the court from Births, Deaths and Marriages, just 3 per cent of death certificates were left unaltered, which Ms Spooner said suggested "a low frequency of accurate and correct completion of death certificates".

She recommended the Medical Board of Australia's Victorian division and the Health Department remind its members and hospitals, respectively, of their legal obligation to report reportable deaths.

She also recommended the Health Department consider implementing a peer review process for death certificates before they were submitted to Births, Deaths and Marriages.